Congenital or acquired micromastia is a commonly encountered clinical condition. The association between a feminine appearing breast and a positive self-image is strong. According to the American Society for Aesthetic Plastic Surgery (ASAPS), 307,230 breast augmentation procedures were performed in 2008. With both the publicity and the relative success of breast augmentation, plastic surgeons must make an effort to be educated in the arenas of patient selection, technique selection, perioperative surgical management, complications, and patient counseling relative to breast augmentation.
The breast is made up of both fatty and glandular tissues. The ratio of the fatty to glandular tissue varies with age and among individuals. Younger women have a higher proportion of the dense glandular tissue composing their breasts, while older women have a higher fatty component. As estrogen production decreases during menopause, glandular breast tissue atrophies, and the fatty tissue predominates in proportion.
The suspensory ligaments of Cooper run throughout the breast parenchyma from the deep pectoralis fascia to the dermis of the skin and provide a support structure for the soft tissues of the breast. With age and the long-standing effects of gravity, these ligaments relax and result in breast ptosis.
The female breast extends from approximately the second rib superiorly to the fifth rib inferiorly. The superior portion overlies the pectoralis major muscle, the serratus anterior muscle inferiorly, and the axillary fascia laterally. The pectoralis major is extremely important in providing muscle coverage for the breast implant in the subpectorally augmented breast. The serratus anterior muscle may also be elevated during breast reconstruction to obtain a sufficient muscle layer laterally to provide complete muscle coverage for an expander or implant. The rectus fascia often must be elevated to place the implant or expander in an inferior position when lowering the inframammary fold (IMF).
The blood supply to the breast is derived from the perforating branches of the internal mammary artery, the thoracodorsal artery, the lateral thoracic artery, the thoracoacromial artery and the lateral intercostal perforators. The blood from these arteries supports the glandular tissues, soft tissue, while the breast skin relies on the subdermal capillary plexus for vascular support.
Sensory innervation of the breast is mainly derived from the anterolateral and anteromedial branches of thoracic intercostal nerves T3–T5. Supraclavicular nerves from the lower fibers of the cervical plexus (C3–C4) also provide innervation to the upper and lateral portions of the breast. Sensation to the nipple is mainly derived from the lateral cutaneous branch of T4, which enters the nipple areola complex (NAC) inferolaterally.
PATIENT EVALUATION & SELECTION
Most breast augmentation procedures are performed to correct glandular hypoplasia, breast asymmetry, or a combination of both. It is important to identify patients with unrealistic expectations for the operation, and those who expect their newfound self-esteem to resolve problems in their personal lives. Such patients ...